Niswonger Children’s Hospital
Family Advisory Council Member Application Form

Thank you for your interest in becoming a council member on the Niswonger Children’s Hospital Family Advisory Council. Please be assured that any information provided in this application is handled with the upmost confidence.

Which method is most convenient to contact you?*

Please describe your child's medical story:*

We would also like to know which parts of the hospital you are familiar with.

Council members will be consulted for advice from different departments and units within the hospital. Please pick those departments or units with which you have had experience.*

Council members on the Family Advisory Council will collaborate with hospital staff on a regular basis. Please explain why you think parents and staff working together on different projects is beneficial.*


Did you receive the Patient Admission Packet when you were admitted? Did this information assist you during your stay?*


What types of information do you wish you had at the time of your stay?*


How did you hear about the Family Advisory Council? (website; mailing; brochure or flyer in the hospital; staff member referral; fellow parent, etc.)*

Hospital Recommendation
We would like to ask a hospital staff member to support your application.
Please give us the name of a doctor, nurse, child-life specialist, social worker,
or any other staff member who would recommend you.